Nursing Programs Work Experience Verification Form
Directions: Students must have 640 hours of work experience (full time or part time employment) in an
acute care, long term care, or equivalent setting as a CNAI (or waiver approved occupation with
certification). If the student is finishing a State Approved CNAI Course by the program application deadline and
does not have time to obtain 640 hours of work experience a letter of recommendation from the CNAI Instructor
who taught the CNAI class/clinical can be accepted. The letter of recommendation should address the student’s
CNAI knowledge, skills and clinical ability including the time frame observed. The letter of recommendation can
only be used in place of the 640 hours of work experience if the CNAI course was taken no more than one year
from the program application date.
Student Name:
Student ID Number:
Date Submitted:
Student meets qualification of (Please check one):
640 hours full or part time employment in acute care or long-term care
640 hours full or part time employment in equivalent setting (as described below)
Letter of recommendation from CNAI instructor
Verification (Please complete appropriate section based on qualifications above)
1. Place of acute care, long term care, or equivalent employment (name, address, phone number)
Description of place of employment if equivalent
Dates of employment and hours worked
By signing below, I indicate that the above listed employee has been employed at the facility for the time and
hours listed above.
Printed Name of Supervisor Signature of Supervisor Date
Rev. 4/27/2020
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signature
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